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Noise in the critical care unit can have negative effects on the patient. Which of the following interventions assists in reducing noise levels in the criticala cbiarbr.ec osme/ttetisnt g? (Select all that apply.)
- A. Asking the family to bring in the patient’s i-Pod or other device with favorite music.
- B. Inviting the volunteer harpist to play on the unit on a re gular basis.
- C. Remodeling the unit to have two-patient rooms to facil itate nursing care.
- D. Remodeling the unit to install acoustical ceiling tiles.
Correct Answer: A
Rationale: Step 1: Bringing in the patient's i-Pod with favorite music can provide personalized, soothing sounds, reducing stress and anxiety for the patient.
Step 2: Familiar music can create a calming environment, distracting the patient from external noise.
Step 3: Listening to music may improve patient comfort and overall experience in the critical care unit.
Summary: Option A is correct as it directly addresses noise reduction by providing a personalized, calming environment for the patient. Options B, C, and D do not specifically target noise reduction but focus on other aspects of care or facility improvement.
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The nurse discharging a patient diagnosed with asthma ins tructs the patient to prevent exacerbation by taking what action?
- A. Obtaining an appointment for follow-up pulmonary fuanbcirtbi.oconm s/tteusdt ies 1 week after discharge.
- B. Limiting activity until patient is able to climb two flights of stairs.
- C. Taking all asthma medications as prescribed.
- D. Taking medications on a “prn” basis according to symapbtiorbm.cosm. /test
Correct Answer: C
Rationale: The correct answer is C: Taking all asthma medications as prescribed. This is the most appropriate action to prevent exacerbation of asthma symptoms. By taking medications as prescribed, the patient can effectively manage and control their asthma, reducing the risk of exacerbation. Following the prescribed medication regimen helps to keep inflammation in check and maintain airway function.
Choice A is incorrect because while follow-up appointments are important, they do not directly prevent exacerbation. Choice B is incorrect as limiting activity may not address the underlying cause of exacerbation. Choice D is incorrect as taking medications on an "as needed" basis may not provide consistent control of asthma symptoms, leading to potential exacerbation.
The nurse identifies a client's needs and formulates the nursing problem of, 'Imbalanced nutrition: less than body requirements, related to mental impairment and decreased intake, as evidenced by increasing confusion and weight loss of more than 30 pounds over the last 6 months.' Which short-term goal is best for this client?
- A. Verbalize understanding of plan and of intention to eat meals.
- B. Eat 50% of six small meals each day by the end of one week.
- C. Meals prepared during hospitalization will be fed by the nurse.
- D. Demonstrate progressive weight gain toward the ideal weight.
Correct Answer: B
Rationale: The correct short-term goal for the client with imbalanced nutrition is choice B: Eat 50% of six small meals each day by the end of one week. This goal is specific, measurable, achievable, relevant, and time-bound (SMART). By setting a goal for the client to eat a specific amount of meals within a defined timeframe, it allows for objective monitoring of progress. This goal also addresses the client's decreased intake and aims to improve their nutritional status gradually.
Choice A is incorrect as verbalizing understanding does not directly address the client's nutritional needs. Choice C is not appropriate as it does not promote independence in meal consumption. Choice D is not the best short-term goal as it focuses on the outcome of weight gain rather than the process of increasing food intake. Overall, choice B is the most appropriate short-term goal as it targets the client's specific nutritional needs and provides a clear direction for intervention.
The patient is getting hemodialysis for the second time when he complains of a headache and nausea and, a little later, of becoming confused. The nurse realizes these are symptoms of
- A. dialyzer membrane incompatibility.
- B. a shift in potassium levels.
- C. dialysis disequilibrium syndrome.
- D. hypothermia.
Correct Answer: C
Rationale: The correct answer is C: dialysis disequilibrium syndrome. This occurs when there is a rapid decrease in urea concentration in the blood during hemodialysis, causing fluid shifts and cerebral edema leading to symptoms like headache, nausea, and confusion. Dialyzer membrane incompatibility (A) would present with allergic reactions, not neurological symptoms. A shift in potassium levels (B) may cause muscle weakness or cardiac arrhythmias, but not the described symptoms. Hypothermia (D) would present with low body temperature and shivering, not the neurological symptoms mentioned.
The patient is admitted with acute kidney injury from a postrenal cause. Acceptable treatments for that diagnosis include: (Select all that apply.)
- A. bladder catheterization.
- B. increasing fluid volume intake.
- C. ureteral stenting.
- D. placement of nephrostomy tubes.
Correct Answer: A
Rationale: Step-by-step rationale:
1. Bladder catheterization helps relieve urinary obstruction, a common postrenal cause of acute kidney injury.
2. By draining urine from the bladder, it prevents further damage to the kidneys.
3. This intervention addresses the underlying cause of the kidney injury, leading to improvement.
Summary:
- Choice A is correct as it directly addresses the postrenal cause by relieving urinary obstruction.
- Choices B, C, and D are incorrect as they do not target the specific postrenal cause of acute kidney injury.
While family members are visiting, a patient has a respiratory arrest and is being resuscitated. Which action by the nurse is best?
- A. Ask family members if they wish to remain in the room during the resuscitation.
- B. Take the family members quickly out of the patient's room and remain with them.
- C. Assign a staff member to wait with family members just outside the patient's room.
- D. Encourage family members to stay, but advise them on the potential stress of the situation.
Correct Answer: A
Rationale: The correct answer is A because it respects the patient's right to privacy while also acknowledging the family's presence. By asking family members if they wish to remain in the room, the nurse allows them to make an informed decision based on their comfort level. This approach fosters open communication and shows respect for the family's emotions.
Choice B is incorrect because abruptly removing family members can increase their distress and feelings of powerlessness. Choice C is incorrect as it places the burden of support solely on a staff member, potentially isolating the family from the situation. Choice D is incorrect as it assumes family members should stay without considering their preferences or emotional well-being.